Results Summary
What was the research about?
The stress of being a mental health counselor can lead to job burnout. When counselors have burnout, they may feel worn out, have negative thoughts about their work, or think they are not good at their jobs.
In this study, the research team used a training program called BREATHE which stands for Burnout Reduction: Enhanced Awareness, Tools, Handouts, and Education. BREATHE teaches counselors to think in new ways, set limits with patients, and find the social support they need.
The research team wanted to see if BREATHE would help
- Counselors have less job burnout and feel better about their work
- Counselors to provide patient-centered care, which respects patients’ preferences, needs, and values and uses those values to guide healthcare decisions
- Increase patients’ satisfaction with care and confidence to manage their own mental health
- Improve patients’ mental and physical health
The research team compared counselors who took part in BREATHE with those who took part in training on motivational interviewing, or MI. Counselors in the MI group learned how to help patients set their own goals for care.
What were the results?
Compared with counselors in the MI group, counselors in the BREATHE group didn’t report less burnout, feeling better about their work, or providing more patient-centered care. Also, compared to the beginning of the study, counselors in the BREATHE group did not report less job burnout over time.
Patients with a counselor in the BREATHE group were more likely to take their medicine correctly compared with patients with a counselor in the MI group. But the patients of BREATHE-trained counselors reported receiving less patient-centered care than patients with MI-trained counselors did. Patients in both groups reported improvements in their confidence to manage their own mental health, satisfaction with their care, and mental and physical health.
Who was in the study?
The study included 192 mental health counselors and 470 of their adult patients. Counselors and patients came from two health centers that provide substance abuse and mental health services. One clinic was in St. Louis, Missouri; the other was in the rural town of Logansport, Indiana. Of the 192 clinicians, 84 percent were white and 80 percent were female. Of the 470 patients, 52 percent were white, and 48 percent were female. Most patients had a high school degree or more education (70 percent) and were unemployed (87 percent). The average patient age was 45.
What did the research team do?
The research team assigned counselors by chance to be in the BREATHE group or the MI group. The team then selected by chance which of the counselors’ patients they invited to take part.
Counselors completed surveys when the study began and then after 3, 6, and 12 months. The research team interviewed patients when the study began and 6 and 12 months later.
The research team asked patients and counselors for feedback on the study design and on how to interpret the results.
What were the limits of the study?
Counselors in this study reported low amounts of job burnout when the study began. The low burnout levels made it hard to see if the BREATHE program helped reduce burnout. About 37 percent of the counselors did not stay in the study until the end. The main reason they dropped out was because they left their jobs at the clinic. The results might have been different if more counselors had stayed in the study. This study only included counselors and patients from two mental health centers. Results might be different in other locations or settings.
Future studies could look at which mental health counselors would benefit the most from programs to reduce burnout.
How can people use the results?
Researchers can use these results to find other ways to reduce burnout for mental health counselors.
Professional Abstract
Objective
To evaluate the effectiveness of the BREATHE intervention for mental health clinicians, compared with a training in motivational interviewing (MI), in reducing clinician burnout and improving patient-centered care and patient health
Study Design
Design Element | Description |
---|---|
Design | Randomized controlled trial |
Population | 192 mental health clinicians and 470 adult patients from 2 community mental health centers |
Interventions/ Comparators |
|
Outcomes |
Primary: clinician burnout Secondary: clinician job-related well-being, clinician and patient perception of quality of care, patient perception of patient-centered care, patient confidence for mental health management, patient satisfaction, proportion of appointments kept, medication adherence, patient health and mental health outcomes |
Timeframe | 12-month follow-up for primary outcome |
This randomized controlled trial examined whether a program to reduce burnout among mental health clinicians, called BREATHE, would also improve patient-centered care and health outcomes. BREATHE stands for Burnout Reduction: Enhanced Awareness, Tools, Handouts, and Education.
The study included mental health clinicians and their adult patients. Participants were from one urban health center in St. Louis, Missouri, and one rural health center in Logansport, Indiana. Both centers provided substance abuse and mental health services. Of the 192 clinicians in the study, 84% were white and 80% were female. Of the 470 patients, 52% were white and 48% were female. In addition, 70% of patients had completed at least high school, and 87% were unemployed. The mean patient age was 45.
Researchers randomly assigned participating clinicians to one of two groups. Clinicians in the BREATHE intervention group received training to reduce burnout using mindfulness, healthier thinking strategies, boundary setting, social support mobilization, and relapse prevention. The training used a group workshop format. Clinicians in the BREATHE group also received materials designed to help them identify burnout signs and triggers and develop ongoing self-care. The second group of clinicians received training in MI, a patient-centered therapeutic approach to help patients set their own goals for care. The researchers included the MI group as a control group that would also potentially improve patient-centered care and patient health. The research team randomly invited patients from the caseloads of participating clinicians to take part in the study.
Clinicians completed surveys at baseline, and then at 3, 6, and 12 months after baseline. Researchers interviewed patients at baseline and at 6 and 12 months after baseline.
Patients and clinicians provided input on the research design and helped interpret the results.
Results
Researchers found no significant differences between the clinicians in the BREATHE and MI groups for any of the clinician outcomes. In addition, clinicians in the BREATHE group did not show significant improvement in burnout or any of the secondary clinician outcomes compared to baseline.
Over the course of the study, patients associated with a clinician in the BREATHE group showed higher medication adherence (p=0.04) and larger decreases in patient perception of patient-centered care (p=0.05) compared with patients of a clinician in the MI group. Researchers found no other significant differences between the two patient groups. However, patients in both groups showed significant improvement in confidence for managing mental health, satisfaction with care, as well as mental and physical health outcomes, including depression and anxiety.
Limitations
Participating clinicians reported low levels of burnout at the beginning of the study, limiting the ability of the researchers to determine the effectiveness of the BREATHE intervention for reducing burnout. In addition, 37% percent of clinicians did not complete data collection at all three time points, primarily because they left the organization. This turnover may have made it more difficult to find differences between groups. The study included clinicians and patients from only two mental health centers in two geographic locations, limiting the generalizability of the findings to other settings and locations.
Conclusions and Relevance
The BREATHE program did not reduce clinician burnout and was not more effective than MI training for reducing clinician burnout or for improving patient-centered care or most patient outcomes.
Future Research Needs
Future studies could seek to identify the most effective ways to reduce burnout among mental health clinicians. Researchers could also identify and work with mental health clinicians most in need of interventions to address burnout.
Final Research Report
View this project's final research report.
Journal Citations
Results of This Project
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also confirms that the research has followed PCORI’s Methodology Standards. During peer review, experts who were not members of the research team read a draft report of the research. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. Reviewers do not have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve how the research team analyzed its results or reported its conclusions. Learn more about PCORI’s peer-review process here.
In response to peer review, the PI made changes including
- Providing a rationale for structuring the intervention as individual-focused rather than group-focused. The researchers added details about the empirical support for individual-focused interventions.
- Indicating that although the between-group differences in the outcome measures were statistically significant, the practical significance of the differences was quite small.
- Describing their sensitivity analyses to determine the impact of key assumptions. As a test of the robustness of the trial results, the investigators asked whether varying the levels of intervention exposure, frequency of use, and perceived helpfulness of specific intervention strategies led to different conclusions about intervention effectiveness.
- Adding a rationale for including clinicians who were not already experiencing burnout by stating that the intervention could help prevent future burnout, and that there were no empirically validated cut-off points for low-level burnout. The researchers also noted that some patients who had little or no connection to participating clinicians were recruited because it was not possible to know patients’ involvement with specific clinicians until after study enrollment.
- Discussing the possibility that contamination, where control clinicians had access to the intervention through their interactions with intervention clinicians, contributed to small difference between groups. The researchers elaborated on this issue, but indicated that contamination was unlikely to be the cause of the results because neither study group improved.